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Including Billing & Diagnosis Codes In Patient Charts

Are you required to include CPT and Diagnosis codes within your patients’ charts?

If so, this guide document goes over how you can do so in Jane!

Adding Billing Codes While Charting From the Day Sheet

If you are charting from the Day Sheet, you may have noticed the Edit Billing Codes blue text at the bottom of your chart entry.

If you click this text, Jane gives you the option of adding Private Billing Codes and/or a Claim to the appointment the chart entry is connected to.

If you choose to add Private Billing Codes or a Claim from this area, Jane will add them to the appointment that the chart entry is attached to. However, NOTHING that you add to this area will be included or saved in the chart entry itself.

Essentially, using the Edit Billing Codes area when charting from the Day Sheet is just another way of adding billing codes and claims to the Insurance Info section of the appointment.

If you would like to include the applied billing and/or diagnosis codes in the patient’s chart entry, you will need to do so by manually entering them in using some sort of chart item (i.e. a Note, Dropdown, or Check box).

Adding a Place for Codes to Your Chart Templates

When creating a chart template, you can use Note, Drop Down, and/or Check Box items to manually enter codes into your chart entries.

If you were to use a Drop Down item, you could include your most popular codes as options within the drop down, and select the relevant code(s) when charting for your patient.

Similarly, if you were to use a check box item, you could include each of your most popular codes as check box options, and check off the relevant code(s) when charting for a patient.

Lastly, if you were to use a Note, you could simply type in the code(s) relevant to the patient’s visit.

For a refresher on how to create and edit your chart templates, please have a look at the following guide documents:

Creating a Chart Template

Chart Parts for Creating a Chart Template

Contact Your College or Licensing Body For More Info

Please note that the use of Drop Downs, Notes, and Check Boxes in your charts for the purpose of including codes is merely a suggestion! It’s best to contact your college or licensing body as to what their specific requirements are for displaying codes in your chart entries.